Quick Reference Card

[Pages:2]Quick Reference Card

This handout is based on Washington State Dept. of Labor & Industries' Medical Aid Rules and Fee Schedules. For complete billing rules and payment policies, see Lni.FeeSchedules.

Effective July 1, 2019 through Sept. 30, 2020

Procedure Description Activity Prescription (APF) Form

Limits*

Attending Physician (AP), per insurer request or self-generate (see limits*)

Procedure Codes 1073M

Non-Facility Fee** Facility Fee $53.41

Chiropractic care (Level 1 ? 3)

One per day

2050A ? 2052A

$ 4 4.73 ? $ 69.82

Consultation including report Electronic communication

MD, DO, ARNP Approved Chiropractic Consultants Physician Non-physician

99241 ? 99245 99241 ? 9924 4 99444 98969

$ 88.69 ? $ 414.98 $88.69 ? $ 340.53

$46.97 $46.97

$ 60.21 ? $ 352.19 $88.69 ? $284.86

$44.50 $44.50

Final Report by AP

AP

1026M

$27.15

Functional Capacity Evaluation Report (review)

Impairment Rating by AP (limited to these provider types) Independent Medical Exam (IME), Report review

Written report post review Job descriptions or analysis (first one reviewed), or

Job offer or analysis: each additional review

AP, per insurer request MD, DO, DPM, DDS. Also DCs, if approved IME examiners AP, per insurer request

AP, per insurer, employer or vocational provider (VRC) request

1097M

1191M ? 1192M 1063M 1065M 1038M

1028M

$53.41

$ 618.4 0 ? $ 773.00 $41.09 $30.82 $53.41

$40.07

Loss of Earning Power

AP, per insurer request

Occupational Disease History Report, Review of worker information and preparation of report

AP, per insurer request

Opioids: Chronic opioid request form

AP / Prescriber

1027M 1055M 1078M

$20.55 $199.32 $32.87

Opioids: Subacute opioid request form with documentation

AP / Prescriber

1077M

$61.64

Opioids: Subacute opioid request form without documentation

AP / Prescriber

1076M

$32.87

Physical medicine procedures by non-physical medicine AP

6 units per claim

1044M

$46.72

Reopening Application Report of Accident (ROA) or the Provider's Initial Report (PIR)

Note: Add an additional $10 to your fee when filing online.

AP

AP, if received within: 5 business days 6-8 business days 9 or more business days

1041M 1040M

$53.41

$41.09

$31.09

OVER

$21.09

Procedure Description Return to Work request, written response to

Limits*

Procedure Codes

AP, per insurer, employer or VRC request ? one per day,

1074M

Non-Facility Fee** Facility Fee $32.87

60 day report (must be in SOAPER format)

AP, one per 60 days

99080

$47.25

Special Report Team conference, patient present Team conference, patient not present Telephone calls with employer, claim manager, other providers, or VRC

AP, per insurer, employer or VRC request ? one per day

99080

Physician only

Approp. E&M

Non-physician

99366

Physician only

99367

Non-physician

99368

Physician only

99 4 41 ? 99 4 4 3

Non-physician

98966 ? 98968

$47.25

Varies by code

$79.63

$78.34

$159.44

$113.09

$68.62

$68.62

$26.54 ? $73.80

$ 2 3.95 ? $ 71.21

$26.54 ? $73.80

$ 2 3.95 ? $ 71.21

*Limits AP ? Attending providers: A person licensed to practice as: MD, DO, ND, DC, DM, PAC and ARNP's. (PAC are paid at a maximum of 90% of the allowed fee.) Non-physician: ARNP, PAC, PhD, PT, and OT must bill using non-physician codes. APF Limits: A network provider may submit up to 6 APFs per worker within the first 60 days of the initial visit date and then up to 4 times per 60 days thereafter.

Note: Beyond the initial visit to file the Report of Accident, only network providers can treat injured workers. Learn more at Lni.ProviderNetwork.

**When a single fee is listed, it applies to both non-facilities and facilities.

Working with L&I

For Medical Providers: Lni.patient-care Billing and Payment Authorizations Treating Patients Improving Occupational Health Care (Healthy Worker 2020)

Billing Self-Insured Employers (under Billing and Payment) Find list of self-insured employers, including contact information Get help resolving billing disputes Note: Self-insurers must follow the same rules and fee schedules as L&I.

Attending Provider Resource Center: Lni.APResourceCenter What attending providers need to know Online CME activity for a maximum of 3 AMA PRA Category 1 CreditsTM

My L&I for Providers Find and use claim-related data, for example, claim status, files notes, and

medical reports

Send a secure message to the claim manager Use Provider Express Billing and retrieve copies of Remittance Advice Submit a Report of Accident online

PUBLICATION F245-414-000 [08-2020]

Upon request, foreign language support and formats for persons with disabilities are available. Call 1-800-547-8367. TDD users, call 711. L&I is an equal opportunity employer.

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